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R.es^-ric^ed 




NAVY DBPARTMB^T 



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i\ <l i tj <? S 1 of 1 1 m <? J. tj intoxm a t i O n p: ::: : :- 



EDITORS 



Captain W. W. Hall, (mc) u, s. n. 
CoMDR. F. R. Bailey, (mc) u. s, n. r. 



Vol. 3 



Friday, March 17, 1944 



No. 6 



TABLE OF CONTENTS 



Immunizations: Overseas Duty 1 

Detergents for Fuel Oil. 3 

Nerves: Primary Surgery 3 

Erratum 4 

Minor Burns, Local Treatment 4 

Sodium Ion in Shock Therapy 5 

Whole Blood Transfusions 7 

Thiourea and Agranulocytosis ...9 

Goitrogenic Substances 9 



orm Letters: 



Control of Streptococcal Diseases 

Ship Medical Department Allotments... 
Venereal Disease Educational Leaflets 



Vitamin C in Man 9 

Experimental Diabetes 12 

Inner Ear Injury by Loud Tones.... 13 
Fibrin Mesh in Nephrolithotomy... 13 

Typing of Enteric Pathogens 14 

White Line a Survival Aid 15 

Care of the Wounded - SGO, AUS.. 16 

Public Health Foreign Report 24 

N.M.R.L Reports 25 



BuMed 26 

BuMed 26 

BuMed 28 



^ it= ^ ^ ^ 



Immunizations Preparatory to Departure Overseas by Aircraft : Air travel 
by small groups of , naval personnel on detached duty is becoming more and more 
common. As a part of his regular duty, the medical officer of the naval activity 
from which such a group is to be detached is expected to foresee the immuniza- 
tions which will be required for the group in the various areas to be visited and 
to provide the necessary immunizations before embarkation. Although the effort 
to foresee the needs of such a group may prove somewhat difficult, the effort 
should nevertheless be made, not only in order to prevent the possible occurence 
of certain diseases but also to obviate the delay and confusion caused by the 
failure of any members of the group to meet the varied immunization require- 
ments of the areas visited. As an aid to the naval medical officer in his effort 
to meet this additional responsibility effectively, the following suggestions are 
offered: 

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Burned News Letter, Vol-. 3, No. 6 



RESTRICTED 



(1) Check the ^'generally required" inoculations (Burned News Letter, 
Vol. 1, No. 4, April 16, 1943) with these points in mind: 

(a) If smallpox vaccination has not been received within a year prior f 
to departure, inoculate. 

(b) If the original series of 3 subcutaneous injections or a repeat in- 
oculation of 0.1 c.c. of typhoid-paratyphoid vaccine intracutaneously has not 
been received within a year prior to departure, inoculate. 

(c) If the original series of 2 intramuscular injections of 0.5 c-.c. of 
alum-precipitated tetanus toxoid has not been received, or has been received 
more than 1 year prior to departure and the usual booster dose has not been 
received, inoculate. 

(d) If the original subcutaneous injection or the repeat inoculation of 
0.5 c.c. of yellow fever vaccine subcutaneously has not been received within 

2 years prior to departure, inoculate. (Yellow fever vaccinations of personnel 
enroute to India should be given at least 14 days before embarkation.) 

(2) Obtain the projected itinerary of the group and determine whether it 
includes areas in which plague, cholera, or louse-borne-epidemic typhus fever 
is endemic. (''Notes on Tropical and Exotic Diseases of Naval Importance" 
contains in its 1943 edition maps of the world showing in color the distribution 
of the important diseases. This publication was distributed to all naval medical 
officers by the Naval Medical School, National Naval Medical Center, Bethesda, 
Maryland. ''Health Precautions for Personnel on Detached Duty" lists the main 
disease hazards for the chief countries of the world. Copies of this publication 
are available upon request to BuMed.) 

(3) Determine which of the "specially required" inoculations will be needed 
with these points in mind: 

(a) Groups destined for Europe, Africa, Asia or South America should 
receive an original series of 3 subcutaneous injections or a repeat inoculation 
of 1 c.c. of typhus vaccine subcutaneously within 6 months prior to departure. 

(b) At the present time there appears to be no valid reason for immu- 
nizing, with typhus vaccine, naval personnel destined for the Central Pacific, , 
South Pacific or Southwest Pacific areas. 

(c) Cholera vaccination is recommended for groups destined for Egypt 

and points east. This should include an original series of 2 injections subcu- ^ 
taneously or a repeat inoculation of 1 c.c. of cholera vaccine subcutaneously 
within 6 months prior to departure. 

(d) Plague vaccination is recommended for groups destined for Morocco, 
Egypt, Palestine, Iran and India. This should include an original series of 2 
injections subcutaneously or a repeat inoculation of 1 c.c. of plague vaccine 
subcutaneously within 4 months prior to departure. 



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(4) Complete the Health Record of each member of the group, adding the 
record of the recently received inoculations upon the Medical Abstract Sheet 
(Form H-3). 

(5) Provide each member of the group with a duplicate copy of his immu- 
nization record (Medical Dept. Form H-3) properly prepared and available for" 
examination prior to departure from his home base in the Continental United 
States for overseas destinations. (D.F.S.) 

^ 9j( 3^ 4^ ^ ^ 

Superiority of Liquid Petrolatum in the Removal of Fuel Oil from Burns 
and Wounds: A comparative study has been made at the Naval Medical Research 
Institute of the forty-four most promising detergents, oil mixtures, and oils, in- 
cluding liquid petrolatum and coconut oil. 

The findings indicate that liquid petrolatum is the best all-around agent at 
all temperatures for the practical removal of fuel oil from intact skin, wounds 
and burns. 

In view of this finding and the fact that liquid petrolatum is available in 
practically all naval units afloat and ashore, one may question the need for pro- 
curement and distribution of special detergent preparations for the purpose of 
removing fuel oil from burns and wounds. (N.M.R.I. Project X-195.) 

)(: + 5(; 3(: 

Primary Treatment of Severed Nerves: When a major nerve trunk is cut, 
its ends, if left alone, retract to a surprising extent. In the ultimate repair of 
these cases at the Chelsea Naval Hospital three to nine months after combat 
wounding, Captain J. C. White (MC), USNR, has found that the gap between the 
proximal and distal neuromata has varied between 1-1/2 and 4 inches. Defects 
in nerve continuity of this extent are difficult to repair and may necessitate 
primary suture of end-bulbs with subsequent stretching and secondary nerve 
suture, nerve grafting, or even shortening of the limb. Procedures of this sort 
entail an enormous increase in the period of hospitalization as well as a greatly 
reduced chance of functional recovery. Retraction of the severed endings varies 
with the amount of tissue initially destroyed and the subsequent inflammatory 
reaction. Even when a nerve is divided cleanly by a bullet or a minute metallic 
splinter, a two-inch separation is likely to occur. A great deal can be done by 
the surgeon who does the primary debridement to minimize the extent of this 
gap without appreciably increasing the operating time or the risk of subsequent 
infection. With this possibility in mind Captain White makes the following 
suggestions; 



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Burned News Letter, Vol. 3, No. 6 RESTRICTED 



1. Enter in the Health Record the type of nerve injury. Is the interrup- 
tion partial or complete ? What is the primary extent of separation of the 
severed ends ? 

2. Whenever it is possible by flexion of the wrist, elbow, or knee to ap- 
proximate the two cut ends, stitch them together by one or two sutures through 
the full thickness of the stumps. Fine, stainless steel wire is ideal: because, 
if there is secondary infection, it does not act as a foreign body; also, because 
it forms an X-ray marker of the exact point of injury, if no wire is available, 
use the finest silk or even "00" chromic catgut sutures to prevent separation 
of the approximated stumps. Suturing of this sort will not be followed by satis- 
factory regrowth, nor will it even reduce neuroma formation, but, if it prevents 
retraction of the stumps, a great deal will be gained. Sulfanilamide can be dusted 
directly into the wound, but not sulfathiazole, as the latter is an irritant to nerve 
tissue. Immobilize the extremity in a plaster cast. 

3. When direct approximation of the nerve stumps is impossible, tack 
them down loosely on the underlying fascia or muscle, approximating them 
as closely as possible. Here again fine wire sutures are ideal, as they mark 
the exact point on an X-ray film. When these are not available and silk or 
catgut is used, break off the tip of a needle (1 to 2 mm. in length) and anchor 

it in the tissue alongside the proximal and distal stumps as a marker. Sutures 
and improvised markers of this type may slough out, but if they do so, no dam- 
age is done, and if retained much has been gained. 

Tacking the nerve ends down in this fashion. can be done even in the presence 
of mild infection provided the nerve stumps are found exposed in the wound. If 
preliminary handling is properly carried out, all that will be necessary in the 
final repair will be to trim oack the scarred ends and perform an end-to- end 
suture. This can be done with a minimal degree of neurolysis, and the problem 
of securing sufficient slack to avoid tension on the suture line will be enormously 
simplified. 

;^ 3f: ^ 9f: 

Erratum: In the Burned News Letter of March 3, 1944, the page numbered 25 
should have been numbered 26, and vice versa. 

Local Treatment of MiiiQy Burns : McClure and Lam have recently com- 
pleted a survey regarding the treatment of minor burns occurring among the 
250,000 employees of three of the large automobile companies of Detroit. Analy- 
sis of the answers to a questionnaire sent to the industrial surgeons involved 
revealed that 84 different substances were used in the local treatment of 7,608 
cases of minor burns. The authors state that, regardless of what is put on the 



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average minor industrial burn, it is apt to be healed within a week. Some of 
the ointments more commonly employed were tabulated as to the average num- 
ber of days required for healing when they were used. ' The results were as 
follows: 

Days for Healing 

■ 7,0 
6.4 

6.3 



5.9 
4.1 

3.2 .■ 
2.5 

2.0 (J.A.M.A., July 31,'43.) 

jjc 3^ 3^ 5^ 3^ 3^ 

The Role of the Sodium Ion in the Therapy of Shock: Considerable interest 
has been aroused in recent months by the experiments of Rosenthal in the treat- 
ment of shock in mice by means of the administration of sodium salts. In the 
Burned News Letter of March 5, 1943, Rosenthal's early experiments in burn 
shock were mentioned. A more complete summary of his work appeared in the 
News Letter of October 1, 1943. There it was reported that Rosenthal had found 
that in mice subjected to a standard burn of a degree fatal to 97 per cent of the 
animals when untreated, only 5 per cent died when any one of a number of iso- 
tonic sodium salts was administered by mouth. An abstract of a later paper by 
Rosenthal appeared in the Bumed News Letter of November 26, 1943. In this 
he reported similar satisfactory reduction of mortality by the use of sodium 
salts in mice in which shock had been produced under imiform conditions by the 
tourniquet method. 

Recently Rosenthal has been carrying out some experiments with regard to 
the treatment of hemorrhage shock with sodium salts. Mice were subjected to 
standard hemorrhage by cutting off the ends of their tails and immersing the 
proximal ends in citrate solution. Fatal hemorrhage was carried out in two 
stages, therapy being administered between the bleedings. Sodium chloride, 
when given in 0.9 per cent solution in quantities equivalent to 8 per cent of the 
body weight, resulted in survival of the majority of the animals. No difference 
in efficacy was found between the oral and intravenous routes of administration. 
Sodium lactate in milliequivalent solutions was as effective as sodium chloride. 



Remedy 

Tannic Jelly 
Zinc Oxide Ointment 
A Shotgun Proprietary Preparation 

Containing 11 Drugs. 
Foille (A Proprietary Water-in-Oil 

Emulsion prepared by Processing 

Several Drugs in a Vegetable Oil 

Base) 

Sulfonamide Ointment 
Vitamin A-D Ointment 
Boric Acid Ointment 
Petrolatum 



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Burned News Letter, Vol. 3, No. 6 RESTRICTED 



The sodium salts were found to be superior to plasma but inferior to whole 
blood. Whole blood was three times as effective as an equal amount of sodium 
lactate solution. It is therefore apparent that in experimental shock in mice 
produced by hemorrhage, burn or trauma, sodium salts possess emergency 
therapeutic efficiency, as measured by reduction in mortality, when given orally 
or intravenously in adequate amounts. (Rosenthal, To be published in Pub. 
Health Rep.) 

Not enough experimental work has yet been done to justify drawing- definite 
conclusions as to the efficacy of sodium salts in the treatment of shock in man. 

In the Journal of the American Medical Association of January 22, 1943, Fox 
reported the treatment of shock In a number of badly burned individuals by the 
oral administration of sodium lactate. No plasma or other blood substitute was 
given. In the series reported only one patient out of 17 died. However, at a 
recent meeting of the National Research Council Subcommittee on Shock, several 
members working in conjunction with Dr. Charles Fox reported 7 burned patients 
treated exclusively with sodium lactate solution by mouth or stomach tube. Five 
died (four unnecessarily, the attending physicians thought), one was not seriously 
burned (15 per cent burn), while one (40 per cent burn) recovered with the aid 
of saline intravenously and had a prolonged convalescence, anemia and hypopro- 
teinemia. One" of those dying (30 per cent burn) had survived the initisd injury 
and relapsed in the second week with severe anemia, tachycardia and high fever. 
Reinstitution of sodium lactate therapy was followed by death in 48 hours from 
acute pulmonary edema. Most patients were given 4-10 liters of lactate in 12-24 
hours. Many vomited and required administration of lactate via stomach tube. 
Usually they relapsed about 6 hours after treatment began, one requiring saline 
intravenously to restore blood pressure. All attained COg combining powers of 
over 80 vol. per cent very quickly and several had clinical alkalosis with tetany. 

It is apparent, therefore, that Fox's paper does not present an unbiased view 
of the present status of the experimental application to human beings of Rosenthal's 
work with mice. Fox's sweeping conclusions as to the value of this method are 
premature and uncritical. Further studies are in progress or projected in a 
number of civilian clinics. It is hoped that more information will be forthcoming 
as to the true value of this form of treatment and that these studies will advance 
our knowledge with respect to the mechanism of shock. 

Sodium salts cannot be expected to counteract the loss of protein, as in burns 
or hemorrhage, or the loss of blood cells and hemoglobin. 

The experimental treatment of shock due to hemorrhage, burn or trauma, 
by sodium salts alone should be attempted only in clinics equipped to do research 
on this problem. It has no place at the present time in military field surgery. 
However , there is enough evidence at hand to justify the administration of sodium 



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Burned News Letter, Vol. 3, No. 6 



salts tO-palients as an adjunct to plasma therapy md' where blood plasma or 
serum albumin is not available. As salt tablets are usually available, their 
addition to. canteen water in pr.oper amount will provide a supply of physiologi- 
cal saline much to be preferred to watgi" im orai administration to patients in 

■sfc jfc i|t jfc 1^ sfc 

The Importance of Whole Blood Transfusions in Battle Casualttesi ' Itoy 
of the reports received by the Bureau from combat areas emphasize the value 
of trtoSfusions of whole blood in the treatment of battle casualties. 

Plasma is an efficient hemodjmamic blood derivative in the emergency treat- 
ment of shock because its administration is followed by an increase in circulat- 
ing blood volume. It is of use also in the nutrition of patients who are unable to 
take food by mouth, as when given parenterally it provides an appreciable supply 
of protein. Its unique value lies in the facts (a) that it can be preserved for 
long periods flot time^wfflioufe deteriorating, Cb) ifefe'lt can be admifilstesed With- 
out preliminary crossmatching, and (c) that for these reasons it caji be made 
almost universally available for immediate use. 

Plasma is usually prefea^red to 'whcrle- Mood In the ia^satmefiii of buyn shock 
during the stage of hemoconcentration. This preference is based on the fact 
that plasma is more efficient than whole blood in reducing the hemoconcentra- 
tion and consequent increase in blood viscosity of this condition because through 
its ©s».6ti€ aetlcii It dii^aws Interstitial fiuii iiilQ the biQod stream / However , at 
a conference on shock at the National Research Council on December 1, 1943, 
it was the consensus that when plasma was not available, whole blood wi^S- not 
contraindicated in early shock due to burns. (1) 

Most injuries sustained in battle are charactarlzed by considerable hemor- 
rhage, and it has been shown that in extensive burns there is significant de- 
struction of red blood cells. (2) Therefore, most severely injured or burned 
individuals are found after restoration to normal of their blood volume to have 
a redmctlcai in the ixtoaber of circulating red blood cells and Intidi^ atteiJiit- ot 
circulating hemoglolbia. 

At first this anemia has a deleterious effect on the individual through re- 
duction tft the amouht of oa^gn d^ltveriid to theiiss«s. The tilMfes, ittr^sady 
suffering from hypoxia resulting from the recent circulatory failure, are now 
subjected to an hypoxia from another cause: reduction of the o^gen'- carrying 
capacity of the blood. 

After correction of th© hemoconcentration, transfusion with wheels b'l o o d 
should be resorted to as soon as it is available in order to provide en-oug h 



Burned News Letter, Vol. 3, No. 6 RESTRICTED 



hemoglobin to overcome the hypoxia which may exist in spite of normal circu- 
latory dynamics. 

Persistent infection aggravates the anemia by inhibiting the formation of 
red blood cells. Increased red cell formation, as demonstrated by reticulo- 
cytosis, follows control of the infection or 'can be stimulated by whole blood 
transfusion. (3) Hemoglobin regeneration does not take place unless there is 
active red cell formation; therefore, particularly in the presence of infection, 
it is essential that transfusions of whole blood be given. Hemoglobin can be 
utilized by the body to form new hemoglobin when it is given by vein, as in a 
whole blood transfusion. 

The formation of hemoglobin may be modified adversely by other factors 
such as reduction in stores or intake of protein and iron. It may be inhibited 
by infection. Burns and other injuries are usually associated with loss of 
large amounts of body protein. Not only may there be significant loss of blood 
and plasma, but also there is extensive tissue destruction with breakdown of 
protein and excretion in the urine of an excess of nitrogen. It is obvious that 
nitrogen balance should be maintained in order that the supply of protein b e 
adequate for the synthesis of new hemoglobin. ''Hemoglobin in its production 
may draw on the plasma protein but hemoglobin stands apart in the protein 
economy and does not contribute freely to the protein pool. On the other hand, 
the body guards jealously the fabrication oi hemoglobin and given a real need 
for both plasma protein and hemoglobin, the protein flow favors hemoglobin, 
which under these circumstances always is produced in more abundance than 
is plasma protein." (4) Therefore, amino acids and plasma protein needed for 
repair of damaged tissues and for restoration of wasted tissues are diverted 
to the formation of hemoglobin when there is a deficiency in circulating hemo- 
globin. Thus, anemia tends to aggravate wasting and to retard healing. 

In addition to supplying elements needed to overcome the anemia, whole blood 
supplies utilizable plasma proteins including immune substances useful in com- 
bating infections. The practical value of repeated whole blood transfusions in 
correcting the anemia following serious battle injuries is well recognized clini- • 
cally and their use is clearly justified on theoretical grounds. 

(1) Conference of Subcommittee on Shock, National Research Council, 
Dec. 1, '43. 

(2) Shen, Ham and Fleming, New England J. Med., Nov. 4, '43. (abstracted 
Bumed News Letter, Dec. 10, '43.) 

(3) Lyons: Observations upon the Anemia of Chronic Sepsis (Preliminary 
Report to Office of Surgeon General, U. S. Army). 

(4) Whipple, Am. J. M. Sci., Apr. '42. 



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Thiourea and Agranulocytosis: Thiourea and thiouracil were mentioned in 
the Burned News Letter of June 11, 1943, as substances which, when administered 
to experimental animals, lowered the basal metabolic rate, and when adminis- 
tered to patients with hyperthyroidism, produced a remission of their symptoms. 

Recently, Newcomb and Deane have reported a patient who developed severe 
granulocytopenia and thrombocytopenia in the course of the administration of 
thiourea, and Welshman described two cases in which thiouracil seemed to pro- 
duce leukopenia and granulocytopenia. 

The use of these drugs in the treatment of h3;fperthyroidism in humans is 
still in the experimental stage. (Lancet, Feb. 5, '44.) 

Goitrogenic Substances : The recent literature has contained a number of 
reports regarding the goitrogenic properties of various chemical compounds. 
Thiourea, thiouracil, thiocarbamide, potassium thiocyanate, and sulfonamides 
have produced in animals a syndrome characterized by hyperplastic goiter with 
hypofunction of the thyroid gland. Hyperplastic goiter has occurred in humans 
in the course of the treatment of hypertension with potassium thiocyanate. One 
of these cases developed exophthalmos. Ranson,in Means' Laboratory treated 
rats with sulfathiazole and found that they developed both hyperplastic goiter 
and exophthalmos. It is believed that these substances impose some obstruction 
to the completion of the elaboration of thyroid hormone. Means (Am. J. M. Sci., 
Jan. '44.) has presented evidence that exophthalmos is related to a thyroid- 
pituitary secretory imbal^ce in which the thyrotropic hormone of the pituitary 
gains the ascendancy. It is known that the thyrotropic-pituitary hormone is in- 
hibited by thyroid hormone. The effect of these drugs in preventing the formation 
of thyroid hormone may be to release from its normal inhibition the thyrotropic 
hormone of the pituitary, and this may be not without danger. 

Function of Vitamin C in Man : Pijoan and Lozner, in a paper to be pub- 
lished in the New England Journal of Medicine, give an excellent review of the 
function of ascorbic acid in the body economy and present some interesting addi- 
tional observations bearing on laboratory evaluation of vitamin C deficiency and 
on human requirements for this substance. 

The Scorbutic Process: A review of the literature on scurvy leads the 
authors to the following conclusions: In man, other primates and guinea pigs, 
prolonged lack of sufficient ascorbic acid in the diet produces scurvy. It is 
assumed with good evidence that the other animals must be capable of synthe- 
sizing a part of or all of their requirements. However, at no time during the 
life cycle of man is it known that synthesis of ascorbic acid takes place. 



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The scorbutic process is dependent on the depletion of ascorbic acid in 
animal tissues and the resultant morphological change in the intercellular sub- 
stance of certain mesenchymal derivatives. 

In the scorbutic animal the ground substance and fibroblasts are present 
as in the healthy animal, but collagen is not formed. The exact mode of action 
of ascorbic acid is not known. The intercellular substance of bone (osteoid 
tissue) and of teeth (dentine) may be similarly affected by withdrawing ascorbic 
acid. In scurvy all tissues lose collagen. As a result of weakness either in the 
sheath or in the endothelial cement substance, the vessels become more fragile 
and rupture easily upon application of trauma or even "spontaneously." As a 
result, hemorrhages occur, there is fragmentation of muscle fibers, and an 
intense reparative effort is evidenced in the sarcolemma by the striking multi- 
plication of cells. The gums, lacking cement substance, become boggy and 
swollen; secondary infections may occur. 

Stress modifies and to some degree determines the site of the gross lesions. 
Lesions are further modified by growth. For instance, in infants bone changes 
are most striking, but in adults they are almost entirely lacking. Multiple peri- 
osteal hematomata become less and less frequent as the age of the patient in- 
creases. Other lesions include blood-stained effusions into the body cavities. 
There may be bloody diarrhea. 

Clinically, the scorbutic manifestations are often mixed with other nutri- 
tional deficiencies and the picture may be modified somewhat. Rather prominent 
is the anemia that is often associated with scurvy. Recent work, however, tends 
to show that the anemia is most often related to a low iron intake or blood loss. 
It can generally be corrected by. the administration of therapeutically active iron 
salts. 

Other investigations have tended to show that ascorbic acid exerts an effect 
on certain specific enzymes, that it acts as a hydrogen transport agent or a re- 
spiratory catalyst and that it is an inhibitor in the adrenalin- adrenochrome 
oxidation in heart tissue, but these findings have not been conclusively demon- 
strated in vivo and in the main are fortuitous observations in vitro. 

The Laboratory Evaluation of Vitamin C Deficiency and Its Relation to Human 
Requirements: The authors describe an experiment by Crandon in which he in- 
duced scurvy by placing himself on a vitamin-C-free diet. His ascorbic-acid 
pla,sma level dropped to zero within 41 days and remained at zero for a period 
of 13 weeks before the signs of scurvy appeared. On the other hand, the white 
cell-platelet layer level did not fall to zero until just prior to the advent of the 
first signs of scurvy. 

Butler and Cushman have observed that the ascorbic acid content of the 
white cell-platelet layer of centrifuged blood is probably the most accurate 



- 10 - 



indicator of the pre-scorbutic status. These investigators found that this level 
may be well within normal limits (25-38 mg. ascorbic acid per 100 Gm.) even 

in the presence of a very low plasma level. The level in these cells apparently 
represents actual tissue stores of this vitamin. Thus, plasma values of zero 
do not necessarily indicate a scorbutic process unless such values exist con- 
cj#Bii$lafltly with a deficiency of ©Hl-platelet content. It would .appear 

from these studies that a fixed plasma value, no matter how low, provided some 
is present, indicates a positive ascorbic acid economy. Should the plasma 
values continue to drop, but, and this is of even greater importance-, should the 
white cell-platelet values^ drop, a shortage of tbe vitamin M fhe"' dietary must be 

The authors believe that there is no clinical justification for the idea that 
a plasma level above 0.7 mg. per cent is necessary for optimum health. 

Whole blood values, indicating a combination of what exists in the plasma, 
the red cells, and particularly the white cell-platelet layer, will also be a 
better index than cell-free plasma and will fall gradually on a scorbutic diet 
until such time as the traces of ascorbic acid in the white cells and platelets 
are sufficiently low to be unmeasurable when diluted by the plasma and red cells. 

It should be emphasized that the diagnosis of scurvy made without clinical 
signs and solely on the basis of laboratory procedures can never be justified. 
On the other hand, a pre-scorbutic state based on depleted white cell and plate- ■ 
let values as an index is warranted because it is during this period that Crandon 
noted fatigue and weakness as well as certain other changes. 

The authors conclude that vitamin C excretion in the urine and saturation 
tests have no place either as diagnostic tests for scurvy .or as criteria for the 
therapeutic administration of ascorbic acid. Re-absorption of ascorbic acid 
by the kidney tubule, unless complete saturation is present, interferes with the 
^ Value of the former, and the latter test is of no use in view of the fact that any 
fixed value at all in the plasma indicates a state of positive ascorbic acid economy 

■ The Relationship of Ascorbic Acid to Wound Healing: Wounds of scorbutic 
guinea pigs heai slowly and with poor tensile strength. This Is true also # the 
frankly scorbutic human subject. On the other hand the evidence that ascorbic 
acid is necessary for wound healing in the non-scorbutic subject has no founda- 
tion whatsoever. Crandon, after three months of an ascorbic-acid-free diet, 
and with no plasma ascorbic leld for Several months, had perfectly normal 
wound healing as revealed by biopsies of an experimental incision. It was only 
after he had developed clinical scurvy that wound healing was impaired. 

One of the .authors made observations on an adult male who remained on a 
low vitamin C intake for 20 months." The averHfe Wake Wtts Ift Jifs^er day for 
20 months, and at no time was it more than 25 mg. or less than 12 nig. The 



Burned News Letter, Vol: 3, No. 6 RESTRICTED 



plasma ascorbic acid value had remained for the most part at zero with occa- 
sional increase, never exceeding 0,2. The white cell-platelet layer levels, on the 
other hand, always exceeded 25 mg. per 100 Gm. At the end of this period 
while persisting on the same diet, a wound was made in the left midback of the 
subject: an incision 2.5 cm. in length and 1 cm, in depth into the subcutaneous 
tissue. Ten days later biopsy revealed normal healing with ample intercellular 
substance and capillary formation. 

It is thus evident that a daily ascorbic acid dietary intake of between 12 
and 25 mg. which maintained a very low plasma level but a value of 25 mg. per 
100 Gm. in the white cell -platelet layer was sufficient to produce adequate 
wound healing and collagen formation. 

Summary : The use of ascorbic acid, either synthetic or in the diet, is for 
the prevention or treatment of scurvy. With the exception of its possible influ- 
ence on amino acid metabolism in premature infants, no other role can be 
ascribed to the vitamin. A diet cannot be condemned as deficient in this vitamin 
unless a continued linear decline in the whole blood, white cell-platelet layer, 
or other tissue content of the vitamin takes place, the appearance of scurvy 
being conclusive evidence. Relatively small amounts of the vitamin (possibly 
25 mg. or under per day) are necessary to maintain fixed blood or white cell- 
platelet levels. The activity of the subject in certain changes in environment 
may some day be shown to influence the need. So far there is no evidence that 
this is the case. Any static level of the vitamin in the plasma, irrespective of 
how little is present, indicates the absence of scurvy and a positive economy. 

jfc ^ )j|c s(c J^C 

Experimental Diabetes : Alloxan, a ureide of mesoxalic acid, produces, 
when injected into rabbits, a transient hyperglycemia followed by a severe hypo- 
glycemia. If the latter is counteracted by repeated injections of dextrose, the 
animals develop a condition similar to human diabetes. (See Bumed News Letter, 
Aug, 7 and Sept. 17, 1943.) Dunn and his co-workers originally believed that 
the lesion in the pancreas was caused by overstimulation of the islets of 
Langerhans with overproduction of insulin and later death of the cells from over- 
strain. 

However, Hughes, Ware and Young have recently shown that the amount of 
insulin known to be present in the pancreas of the normal rabbit is sufficient, 
when administered as a protamine-zinc preparation, to reproduce the hypogly- 
cemic action of 200 mg. per kg. of alloxan in this animal. As they admit, such 
evidence is not unequivocal, but it suggests that there is no necessity to assume 
that alloxan lowers the blood sugar by any means other than killing islet cells 
which are thus made to liberate their content of preformed and stored insulin. 
(Lancet, Jan. 29, '44.) 

- 12 - 



* 



; ■ . Biun^ Uews Letter Vol. 3, No, ,6 ■ . RESIKECTRD 

- Injury to the Inner Ear bv Loud Tones: Hawkins, Lurie and Davis of the 

Harvard Medical School have recently reported the results of their experimen- 
tal study of injury of the inner ear in animals produced by exposure to loud 
tones. The following passages are quoted from the authors' summary: 

''Guinea pigs were exposed to pure tones of various frequencies.--8it;ftitensi- 
ties of from 140 to 157 db. The effects of 500 cycles and 1,000 cycles were most 
completely explored. Severe and extensive damage to the cochlea may be caused 
by loud tones without apparent injury to the eardrum, ossicles or vestibular appa- 
ratus.. The least detectable anatomical damage to the inner ear, i.e., the disap- 
pearance of mesothelial cells from a limited area of the lower surface of the 
basilar membrane, was produced by 1,000 cycles at 140 db. for 3 minutes. More 
severe and extensive damage is produced by more intense tones and by longer 
exposures, and includes' degeneratlTO ChMiies in the sensory cells, rupture of 
the organ of Corti and dislocation of the organ of Corti from the basilar mem- 
brane. A few days or weeks after severe exposure that part of the organ of 
.Corti which has been severely damaged disappears and the nerve fibers and 
ffflQ^lria:'06lls degenerate.^ ^ . , • '■■ - ' 

The milder degrees of damage are localized, but a very severe exposure 
(150 db. for several minutes) causes widespread permanent damage. The dam- 
age tends to be located nearer the helicotrema when caused by low tones and 
nearer the oval and rouM ^sMl>«.('«^ftm ©««^l.t^'4i^^ ■. ■ - " • 

The electrical activity of the cochlea' CWever and Bray effect or aural 
mLicrophonics) is impaired by exposures which cause definite anatomical changes 
in the inner ear. ■ There is soMi gtoeral ©Sf3P©Sp©tidence betw^fen; 4lteteti^n in 
auditory acuity as measured by the 'electrical audiogram' and the degree of 
anatomical damage, but the parallelism is not exact or invariable. The anatomi- 
cal changes are the more consistent of the two. • • 

Normal cats are far.Mc^re resistant than guinea pigs to injury of the inner 
ear by intense sounds, but severe lesions, have been^jroduced, to aneisthetized 
animals, _ 

J These e3q)erimeflts with animals probably demonstrate the nature of the ■ 
injury to human ears that would be produced by sufficiently intense continuous 
sounds, but they do not indicate the intensities or durations of ejqjosure neces- 
sary to product siieh injury in man." (OEMcmr-Project No. 194, Dec. 31, '43.) 

■ Nephrolithotomy: The Use of Fibrinogen and '^Clotting Globulin": pees 

of small renal calculi/* His method involvijg the injection of a coagulable sub- 
stance into the renal pelvis at open operatio^i so that the resulting clot completely 



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Burned News Letter, Vol. 3, No. 6 RESTRICTED 



fills the pelvis and forms a perfect mold of all its ramifications. Within this 
coagnlum are incorporated all free renal calculi. The coagulum, together with 
all stones enmeshed within it, may then be removed through a pyelotomy 
incision. 

The coagulum Dees employs is fibrinogen obtained from human plasma. 
Fibrinogen is that fraction of plasma globulin which reacts with thrombin 
to form fibrin, and is soluble in normal saline solution but insoluble in water. 
It is rapidly converted into a fibrin clot by the addition of thrombin or clotting 
globulin. Fibrinogen solution may be sterilized by passage through a Seitz 
filter without altering its property of coagulation. At room temperature the 
solution is slowly denatured so that its ability to clot is lost within a few days. 
By freezing, or lyophilizins fibrinogen solution, however, its clotting properties 
may be preserved for weeks or months. The supply of human fibrinogen is 
limited, as a liter of human plasma yields only from 40 to 50 c.c. of concentrated 
fibrinogen solution. As a coagulating agent Dees uses "clotting globulin.'' 
(Lederle) The coagulum is formed by the mixture of 10 parts of human fibrino- 
gen solution and one part of 2 per cent clotting globulin. Coagulation begins 
approximately 30 seconds after mixing and is complete at the end of 60 seconds. 
Within 5 minutes after mixing, the tensile strength of the coagulum is usually 
from 10 to 15 times as great as that of human blood clot. 

Dees' technic of operation involves exposing the kidney pelvis and upper 
ureter; the latter is gently occluded by finger pressure and the urine aspirated 
from the kidney through a number 12 catheter which has been inserted into the 
pelvis through a small incision. The kidney is flushed with saline, then the 
pelvis is lavaged with a solution of fibrinogen after which all fluid is aspirated. 
Fibrinogen solution is injected through the catheter into the pelvis and at the 
same time two per cent clotting globulin is injected by means of a syringe and 
needle through the wall of the catheter so that the two substances are intimately 
admixed as they enter the renal pelvis. After the lapse of five minutes the 
catheter is removed and the usual pyelotomy incision is made. The coagulum 
is grasped with a ring forceps and slowly but firmly withdrawn. It should re- 
move, enmeshed within itself ^ all free calculi. 

Dees made further studies which proved that no harm to the kidney resulted. 

He had used the technic in five clinical cases iip to the time of the report) 
without apparent ill effect. (South M. J., Mar. '43.) (G.J.T.) 

+ * + * + 

TvDing of Enteric Pathogens: The scope of the Salmonella Typing Center 
at the U. S. Naval Medical School (Burned News Letter, Vol. 1, No. 7; U. S. 
Naval Medical Bulletin, 1943, Vol. 41, No. 4, p. 1184) has broadened to include 



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BumeTd News Letter-, Vol. 3, No. 6 



REeramTED 



all of the Qriam-iiegative, enterie pathofem* ©altures of Salinonellas, Shigellas, 
Paracolons, Proteus, and Pseudomonas are being identified in this special 
typing service. . ' - . 

Evidence of the pathogenicity of certain strait^ «rf J>araGolon, Proteus 
and Pseudomonas (hitherto considered doubtful or of little importance) is being 
accumulated. At least one outbreak of otitis externa was apparently caused by 
Pseudomonas aeruginosa. At least one representative of the Paracolon group 
has be^H 'shOWfi tO' b^e ■©losely related to outbreaks of gastrtj-^ettierttts.^ There 
is good reason to believe that Proteus mirabilis has initiated several outbreaks 
of gastro-enteritis. Present organizations present an excellent- opportunity of ■ 
obtaining further information along these lines. 

- Mb^ <!ff th6 ijultitfas "rested by the Typing Ceirt«r hmm bieeri JMSJCed by 
laboratories at naval activities located within the United States. It is urged 
that, if at all possible, more cultures of suspected enteric pathogens found at 
activities outside the continental limits be forwarded for tjrping and the compi- 
lation Of difca. 

It is expected that the epidemiology teams, especially, will find this service 
useful, as their aid is often sought in determining the etiology of epidemics of 
food poisoning. 

When possible, reports on typing of cultures examined are returned within 
a few days after receipt of the organisms. In a few instances, particularly with 
Paracolons, etc, a longer period of time is required for- completing the studies. 
The imp ©rtanea of' an offieial letter of transmittal of specimens is emphasized. 

» * * ''^ ''^ 

Abandon Ship with a Piece of White Line : Ensign P. A. Moody CHC), USN, 
writes in comment regarding the item on ''Abandon Ship" in the Bumed News 
Letter of February 18, 1944, that at the suggestion of the late Commander J. D. 
Blackwood, Jr., senior medical officer, a number of men on the VINCENNES 
carried a' siieath feiife and' te Mdltlon often l^h?aLpped'afOund'lt'a piece of "'white 
line approximately 3 to 4 feet in length, secured so that it would be small in 
size, yet easy to unroll when needed. This advice was followed by most of the 
men, and many who abandoned ship had occasion to use it.' It may be used as 
a haeans of lashing one's self to S i'aft &r Cfther floating object, as a tourniquet 
for a wounded shipmate, or as a lashing for a makeshift splint. 



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Burned News Letter, Vol-. 3, No. 6 ■ RESTRICTED 



Care of The Wounded in Theaters of Operation: The following Circular 
Letter from the Office of the Surgeon General of the U. S. Army is reprinted 
in the Bumed News Letter for the information of Naval Medical Officers: 

ARMY SERVICE FORCES 
Office of The Surgeon General 
Washington 25, D, C. 

CIRCULAR LETTER NO. 178 23 October 1943. 

Subject: Care of the wounded in theaters of operation. 

1. The purpose of this letter is to provide broad policie's and certain 
guiding principles on the care of the wounded in theaters of operation. Modi- 
fication in accordance with existing conditions and changing circumstances 
may be necessary. 

2. Principles of evacuation, a. The lightly wounded whose injury is such 
that treatment would permit immediate return to duty will be treated in the for- 
ward echelons (battalion aid stations, collecting and clearing stations) and will 
not be evacuated. 

b. Patients with injuries requiring immediate operation in order to 
save life will be treated in forward echelons if possible. 

c. With exception of above, no operations will be done in forward echelons. 

d. The lightly wounded who reach a forward hospital should be held in 
convalescent hospitals in that area and not evacuated far to the rear. 

e. So far as possible, seriously wounded patients requiring surgery 
should be evacuated directly to evacuation hospitals or to other hospitals acting 
as such. 

f. Patients who, in the opinion of the responsible medical officer, cannot 
be returned to duty status within the period determined by the evacuation policy 
of the theater (at present 180 days for the European and the China, Burma, India 
Theaters and 120 days for all other overseas theaters, defense commands, de- 
partments, and separate bases) will be returned to the United States on the first 
available and suitable transportation, provided the travel required will not aggra- 
vate their -disabilities. 

3. Treatment, a. Wounds. (1) Soft parts , (a) Roentgenographic or 

fluoroscopic examination should be done preceding 
operation. 



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Burned News Letter, Vol. 3, No.. 6 - RE^mnTRD 

(b) Principles. The fundamental: p^finelpifes.in the festre- eKf. wounds are 
reaffirmed, fecial emphasis is placed on the following; • ■ 

^ . ■ ■■ 1, Adequate;exposure is essential in order to permit access to all 
parts of the wound. This does not mean overexcision of the sldn, Wry little 
skin need be excised but good exposure may necessitate longitudinal incision 
of the skin and the fascial plaiies, 

2. Removal ofr 

aa . Readily accessible foreign bodies; especially important ^e'- 
pieces of clothing and other nonmetallic materials, 

■ -' ■ nJi, - Psrtfeles of b<MQ'ts©ffiplel@ly itpgM^^d #bm the periosteum. 

ac . Tissue that is soiled, devitalized, or the circulation of which 
is impaired (especially certain muscles such as vastus intermedius, rectus 
femoris, hamstrings, gluteus ma^aati&j/^aihe'hettiM'if/tie. ga 

3. Leave woimd open. 

4, Dressing should be placed loosely !n the Wound, not packed. 

5, In large wounds, immobilize the part by adequate splinting even 
in the absence of fractures, 

m Head Wounds. , 

(a) These should be considered as priority cases for evacuation to nearest 
hospital where adequate surgical treatment and r)ostoperatj,ve qare are feasible . 
A transport time of 48 to 72. hours does not ctefe^*sis®;«^¥#vitcuation or justify 
operation forward of an evacuation hospital. 
Before evacuation treat as follows; 

1. -Gently separate edges of scalp, remote ©up^rflelal StrE moti blood 
clot, and cover with sterile gauze, 

2. While gauze is held in place, shave scalp for three inches around 
w©und and wa^h^kin Mth soap an(S%^r; ^ 

3. Remove gauze, frost wound with sulfanilamide, and apply large 
secure dressing. 

Cb) Surgical treatment in hospital. ' 

1. Carefully debride scalp but conserve as much skin and subcutaneous 
tissue as possible. 

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Burned News Letter, Vol. 3, No. 6- RESTRICTED 



2. Bone defect may be enlarged if necessary but avoid extensive 
bone flaps. , . ■ ' 

3. Loose bone fragments and accessible foreign bodies should be 
removed. . 

4. Damaged brain tissue may be removed by gentle irrigation and 

suction. 



5, These wounds should not be packed but closed around a small 

drain. 

(3) Face, (a) Maintenance of a clear respiratory airway is an important 
consideration in these cases before evacuation. If patient cannot sit up, evacuate 
in the prone position. In some cases tongue traction by means of a suture o r 
safety pin may be necessary. 

(b) Surgical treatment. 1. Every effort should be made in operating on 
these wounds to conserve tissue in order to facilitate subsequent reconstructive 
procedures. Foreign bodies and completely detached fragments of bone and 
teeth are removed but fragments of bone which still have some attachment to 
soft tissue are conserved. 

2. In contradistinction to the general rule of leaving war wounds open 
these wounds should be closed if this can be done without exerting undue tension. 

3. If the defect is such that primary closure is not possible and the 
wound enters the buccal cavity, the edges of the skin and mucous membrane 
should be carefully approximated. In cases in which there is an opening into 
the buccal or nasopharyngeal cavities complicated by a compound fracture no 
attempt should be made to suture the wound but the mucous membrane may be 
approximated if possible. Approximation of lacerated soft parts by bandage and 
adhesive strips is preferable in these cases. 

(4) Chest, (a) Sucking wounds of the chest demand immediate closure. 
This should never be done by suture unless adequate debridement of the chest 
wall is possible. As an emergency measure closure is best effected by the 
application of a pad of gauze heavily coated with vaseline and folded to fit the 
wound and held in position by a few sutures through the skin. Over this a sup- 
portive gauze dressing should be strapped securely. These patients should have 
priority in evacuation to hospitals. 

(b) Novocain block of the intercostal nerves supplying the injured area 
is an especially useful procedure not only in simple rib fractures and "stove-in- 
chest" but also in other chest injuries in which pain of the chest wall is an im- 
portant factor. 



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Burned News Letter, Vol. 3, No. 6 



(c) The occurrence of tension pneumothorax should always be considered. 
It may be relieved by aspiration or release 6i air through a needle introduced 
into the chest through the second or third interspace anteriorly. This niay also 
be accomplished by inserting a small catfeieter into the chest and connecting it 
with -a fingeE'COt'~oi!'<3ondldm valve;. ' •.' . . • '•" 

Cd) In the management of simple hemothorax conservatism is desirable. 
Except in progressive hemorrhage, simple aspiration is sufficient to relieve, 
respiratory embarrassment. Air replacement will not be done. Within a few 
days and when the danger of secondary bleeding is past the pleural cavity should 
be enaptied of blood by two or three aspirations on successive days. 

• Ce) When thoracotomy is performed, an effort should be made teristove 
large foreign bodies. Operation in these cases should be preceded by roetgeno-^ 
graphic examination. , . 

(5) Abdomen , (a) Because of the. importance of early operation in penetrat- 
ing wounds of the abdomen and the fact that these patients do not tolerate early 
transportation after operation, these cases should be evacuated direct and as 
soon as possible to the nearest hospital where adequate surgical treatment and 
postoperative care are feasible. . • . . , 

Cb) Cases requiring abdominal cpirafcions should not be moved for five to 
seven days after operations. " , . 

Cc> In view of the frequency with which missiles producing penetrating 

injuries of nearby regions such as the thigh, buttocks, and chest lodge in the ab- 
domen, all such cases should have roentgenographic examination of the abdomen. 

Mif ti panBtratii^^wouiKis of used 
wherever possible in preference to spinal anesthesia. 

(e) In large bowel injuries, the damaged segment will be exteriorized by 
Rawing it otit tl^iugh a separate incision, preferably in the flank. In order to ' 
facilitate subsequent closure the two limbs of the loop should be approximated 
by suture for a distance of about 2-1 /2 inches and then returned to the abdomen 
leaving the apex exteriorized with a short length of rubber tubing or other suita- 
ble material beneath It. If the segment cannot be mobilizetl Qm injury should be 
repaired and a proximal colS^ottf' - 

(f) Penetrating injuries of the rectum should have exploratory laparotomy 
and posterior drainage by excision of the coccyx and incision of the fascia propria. 

(g) Perforating wounds of the bladder require repair and drainage of the 
urine by suprapubic cystostomy or perineal urethrostomy. The space of Retzius 
should always b© drained. ' 



Burned News Letter, Vol. 3, No. 6 RESTRICTED 



(h) Postoperatively, suction on an indwelling gastroduodenal tube is 
recommended and every effort should be made to prevent vomiting and disten- 
tion and to promote physiologic rest of the alimentary tract. 

(6) Extremities, (a) Soft parts. The principles of treatment are the same 
as previously stated. 

, (b) Nerves. 

1. In view of the fact that extremity wounds constitute 75 per cent of 
all battle injuries and that 12 per cent to 15 per cent of all extremity wounds are 
complicated by injury to major nerve trunks, the possibility of nerve damage 
should always be considered. Effort should be directed toward early recogni- 
tion of the existence of nerve injury and suitable notation must be made on the 
E.M.T. tag or on a cast in order to facilitate proper evacuation and the necessary 
early treatment. 

2. Primary nerve suture should be done when the nerve ends are 
readily accessible and can be approximated without tension. If this is not possi- 
ble and the injured nerve ends are identified, a sling suture of fine stainless 
steel wire should be placed between them or they should be anchored with similar 
suture material to the surrounding tissue in order to prevent retraction. The use 
of metal suture material here is desirable because it permits roentgenographic 
identification for subsequent repair. 

3. In view of the irreparable degenerative changes that occur in the 
end plates of severed nerves, early repair of these nerves is absolutely essential. 
For this reason it is of the utmost importance to evacuate these patients as soon 
as possible to the zone of the interior where operative repair and the necessary 
postoperative physiotherapy can be instituted. 

(c) Arteries. Peripheral vascular injuries are of special importance, 
particularly where major vessels are involved. In many of these cases ligation 
will be necessary. Ligation in continuity should not be done, but rather division 
between ligatures above and below the point of injury thus eliminating the danger 
of secondary hemorrhage, thrombosis, and vasoconstrictor influences. In the 
presence of thrombosis, the thrombosed segment should be excised. Localized 
segmental spasm of the artery should be distinguished from thrombosis. Such 
cases which have also been termed ''concussion" or ''stupeur" of the artery 
may follow various forms of trauma to an extremity and especially when the 
traumatizing agent passes near a vessel, in such cases the limb is cold,' pale, 
and pulseless, but evidence of hemorrhage or hematoma indicating that the 
vessel has been lacerated is lacking. These cases respond well to debridement 
of surrounding traumatized tissue and to periarterial sympathectomy or sympa- 
thetic block. Postoperatively in all cases with peripheral vascular injuries 
vasodilatation should be induced by daily sympathetic block using one per cent 



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.^.-^ Burned Mews Letter, Vol. 3y mi & RESTRICTED 

procaine hydrochloride scflutibn. ' Body warmth should be carefully maintained 
but haat phould not be applied to the involved extremity. • ' ■ 

. (d) Bones and joints. 1. Open reductions in the case of simple fractures 
will not be done exce'^t in general hospitals. 

2. Fractures of the femur are to be evacuated from field units to the 
forward hospitals- in the Army half-ring splints using the litter bar, ankle strap, 
and five triangular bandages. If it is necessary to remove the shoe, traction , 
will not be effected by the aiikl© strap Wteh -about the ankle but skin traction 
will be applied, - 

3_ Fractures of the shaft of the femur or tibia and fractures involving 
the hip or knee joints will be evacuated from forward hospitals i©- general hospi- 
tals in the Army half-ring splint with skin or skeletal traction or in aplaster 
spica. The use of the Tobruk splint has received favorable comment. It is ap- 
plied as follows: by means of traction, preferably skin traction, the extremity 
is pulled down, a plaster splint is moulded to the posterior aspect of the thigh 
and leg, a half-ring splint is applied to which the traction is made fast, and the 
extremity and splint are wrapped by several turns of plaster. The application 
of multiple pins incorporated in plaster is not recommended. 

4. In the general hospital fractures of the femur should be treated by 
traction, either skin or skeletal, until enough union has been obtained to permit 
safe transportation to the zone of the interior in a plaster spica. 

5. Fractures of the ankle and foot are best evacuated in padded pos- 
terior s»d lateral wire ladder splint^., 

6. Fractures of the humerus should be transported to the evacuation 
hospitals in the Thomas arm hinged splint with skin traction and triangular band- 
ages. An alternate method is the immobilization of the arm to the side of the 
chest with a sling or velpeau bandage incorporating a padded external splint if 
available. For evacuation to a general hospital, the best method is the use of a 
U-shaped molded plaster splint extending from the axilla around the elbow and 
up the outer surface of the arm and shoulder to itm neck. This is supported by 
bandages and a sling. 

7. Fractures of the elbow and forearm should' bi immobilized in a 
posterior wire ladder or molded plaster splint extending beyond the wrist and 
supported by a, sling. 

8. Penetrating wounds bf the 3©intg should be treated by debridement 
with i-BmOval of loose bone fragments, irrigation of the joint cavity, and closure 
of the synovial membrane. The soft tissue wound down to the sutured synovial 
membrane must be kept open by loosely placed gauze. Whereas in the upper 



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Burned News Letter, Vol. 3, No. 6 RESTRICTED 



extremity all loose bone fragments should be removed, in the lower extremity- 
fragments necessary for stability and weight bearing should be preserved if 
possible. All joint injuries should be immobilized as stated above. 

9. Fracture of the lumbo-dorsal spine should be transported with a 
blanket roll support under the site of fracture. Fractures of the cervical spine 
should have an improvised collar. This may be made using the patients' two 
canvas leggings with hooks of each facing to leave a smooth outer surface. The 
ankle notch is fitted snugly under the "chin; the leggings then are tied by means 
of the laces and tightly wrapped in place with a bandage. This may be used for 
recumbent or ambulatory cases. 

10. All recent casts on the extremities should be padded and should 
be completely bivalved before evacuation. 

(e) Amputations . All primary amputations in the combat zone should be , 
performed at the lowest level possible which permits removal of all devitalized 
and contaminated tissue regardless of stump length. Revision of the stump in 
accordance with prosthetic consideration may subsequently be performed. The 
open circular method of amputation is the procedure of choice in traumatic sur- 
gery under war conditions and is especially indicated in gunshot wounds and in 
controlling infection. Following circular division of the skin which is allowed 
to retract, the muscles are severed at the level of the retracted skin, the outer 
layers being divided first, and, as they contract, the deeper layers until the bone 
is reached. The bone is sawed without stripping the periosteum. These wounds 
must always be left open using a vaseline dressing. Skin traction to the stump 
must always immediately be applied following the amputation and continued until 
healing occurs. The flap type open amputation may be done only in cases in 
which early evacuation is not contemplated and subsequent closure at the same 
station is deemed possible. 

b. Burns. (1) Principles , (a) Prevention and control of shock by the adequate 
use of plasma. In extensive burns, quantities of plasma up to 12 units may be 
required in the first 24 hours. 

Cb) Relief of pain with morphine. Large doses of morphine should b e 
avoided if anoxia is present. 

(c) Prevention and control of infection by aseptic precaution and by the 
oral administration of sulfadiazine. The initial dose of sulfadiazine should be 
4 gm. Subsequent maintenance dosage should be determined by fluid intake, 
urinary outp at, and tolerance for the drug. 

Cd) Prevention of contractures and excessive scarring, by proper splint- 
ing and early skin grafting. 



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Burned News Letter, Vol. 3, No. 6 RESTRICTED 



(2) First-aid or emergency treatment of burned area . Cover witli sterile 
petrolatum or boric acid ointment, then with strips of fine-mesh gauze (gauze 
bandage) . Over this add thick layer of sterile gauze dressing and wrap with 
gauze or muslin bandage to make firm pressure dressing. 

(3) Treatment of burned area when patient arrives at hospital , (a) Standard 
operating room technique with patient and attendant fully masked will be used. 

^ Cafees imffMeh bui*iiest surface appears clean, further preparation will 
not be done. The use of detergents such as lard and washing and debridement 
will be reserved for grossly soiled burns. Small blisters should not be disturbed 
and larger ones drained by simple puncture. General anesthesia should be avoided 
if possible and pain controlled by morphine. * ' r 

(c) Tannic acid and all other escharotics will not be used. 

rjijjg burned area will #6 co^rti #itte iraissiine oi»> if this is not avail- 
able, boric acid ointment and a firm pressure dressing as described under first- 
aid treatment will be applied. In burns of the extremities the pressure dressing 
should include all the extremity distal to the burn. Immobilization of the part 
by splinting should be affecttd wtttn feasible. Unless complications develop, the 
dressing sJaould not be disturbed from 10 days to I weeks. 

c. Gas gangrene. (1) Prophylaxis, (a) Inadequate and delayed debridement 
and primary closure of wounds are two of the most Important factors which con- 
ttlbutoto tte dev^#l<spm@fflft of gas faiigf'ine. ■ 

Cb) Gas gangrene is particularly likely to occur in certain wounds such 
as compound fractures of the long bones, injuries causing extensive muscle 
d£imaga>'ptEMf^l!]A;g wDuatti® «Kf the abdomen, deep womd# M'tt® peifeeiam, and 
wounds in which the circulation of the part has been impaired. This factor of 
impaired circulation is especially important in certain muscles such as the 
gluteus maximus, the hamstrings, rectus femoris, vastus intermedins, and the 
gastrocnemius. Beeause in these muscles the blood supply is peculiar in that 
it is derived from only one or two sources which if cut off may result In ischemia 
of the entire muscle, wounds in these regions may be more frequently associated 
with gas bacillus infection. In performing debridement in these wounds special 
care should be exercised in removing devitalized tissue. Accordingly, cases of 
this nature especially those in which the injury has resulted in loss of the main 
blood supply of the part, will not be evacuated from hospitals until the danger 
from gas gangrene is past. 

(c) The primary closure of wounis' greatly predisposes to the develop- 
ment of gas gangrene. Leave wounds open. 



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Burned News Letter, VoL 3, No, 6 



RESTRICTED 



(2) Treatment , (a) The most important factor in treatment of established 
gas gangrene is early removal of all involved tissue. This frequently necessi- 
tates excision of entire muscle bellies or guillotine amputation. 

(b) Chemotherapy should be maintained. 

(c) Polyvalent gas gangrene antitoxin should be administered preferably 
intravenously, after suitable precautions against anaphylactic shock have been 
taken. A minimum dose of three ampules repeated hourly at the discretion of 
the medical officer until six doses have been administered is recommended. 

(d) Because in gas bacillus infection there is rapid destruction of erythro- 
cytes, whole blood transfusions should be used. 

d. Chemotherapy. (1) The value of sulfonamides in preventing sepsis and 
spreading infections is emphasized. Because this depends in great measure 
upon the systemic presence of the drug, administration by oral or parenteral 
means is considered essential. Sulfadiazine is considered the drug of choice. 
An initial dose of 4 gm. administered orally as soon after injury as possible is 
recommended. Mamtenance dosage of one gm . every four hours should be used 
if adequate kidney function can be assured. 

(2) The untoward reactions and complications of sulfonamide therapy should 
be thoroughly realized. Of these the most important are the renal disturbances. 
Since the great majority of these can be prevented by an adequate urinary out- 
put, every effort should be made to maintain an output of at least 1,500 c.c. daily. 
If this drops to below 1,000 c.c. or if microscopic hematuria develops sulfona- 
mide therapy should be stopped. 



For The Surgeon General: 



ROBERT J. CARPENTER, 
Lieut. Colonel, Medical Corps 
Executive Officer. 



+ 



* 



* 



* 



t: 



Public Health Foreign Report: 



Disease 



Place 



Date 



Number of Cases 



Smallpox 



Algeria 
Indochina 
Mexico, Torreon 



Dec. 1-10, '43 

Dec. 1-20, *43 

Jan. 1- 8, '44 

Jan. 8-15, '44 



122 
204 



9 
10 



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Burned News Letter, Vol. -3, No, 6 



PEbllG Health Foreign Report: ( Omi .) 



Disease 



Place 

Algeria 
Curacao 
Hungary 
Rumania 



Number of Gases 



Dec. 1-10, '43 33 

Jan. 1- 8, '44 1 

Nov. 27-Dec. 4, '43 19 

Dec. 16, '43-Jan. 7, '44 690 



Yellow Fever 



Cape Verde Islands, 
Pi^aia . Jan. 18, '44 

At Lisbon Jan. 21, 



(Pub. Health Rep., Feb. 4, '44.) _ 



1 (suspected) 
t<aas#^ ©a board) 



Reports on Research Projects at the Naval Medical Research Institute 
Available for Medical Officers: 

Amoebicidal EfflslanaF of Various Sterilizing Reagents 'for 'Water in 
■Canteens. 

The St@p-0p Test to Evaiuat© Fltoess for Physioal BmHim In Healthy 
Men, Report No. i. • , 



X-li4 



X-154A Report of an Investigation of Carbon Monoxide Concentration in the 

Hattgar Space and Reaiy Roam of Sseort Aircraft Carrier. (Confidential). 



X-159 



The Design and Construction of a Simplified Electronic Flicker-Fusion 
Apparatus and the Determination of Its Effectiveness in Detecting 



X-161 Dental Anesthesia Induced by Local .Refrigeration. 

X-203A Testing of -CJoggles (TED No. UNL 2533) Electrically Heated Single 
Aperture Type - Manufactured by Qeneral Electric Company. 



X-257 
X-273 



Physiological Appraisal of the British Oxygen Mask, Type "H", 



Physiological Appraisal of A- 10 A OEygSE Mask. 



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Burned News Letter, Vol. 3, No. 6 RESTRICTED 



To: All Ships and Stations. BUMED-Y-HS 

P2-2/NN(103) 

Subj: Control of Streptococcal Diseases. 

26 January 1944 

1. The Bureau is developing principles for the prevention and control of dis- 
eases susceptible to sulfonamide prophylaxis by the use of sulfadiazine. This 
program is being instituted at several of the larger naval activities and a 1 - 
though preliminary reports of the program are quite favorable, the method 
has not been standardized at the present time. Large-scale prophylaxis there- 
fore is contra -indicated. 

2. In order to control the program it is directed that no naval activity institute 
a sulfonamide prophylaxis program for any purpose without prior approval of 
this Bureau. — BuMed. Ross T. Mclntire. 

To: All Ships and Stations. FS/L1-2{012), F-LC 

Subj: Ship Medical Department Allotments, 11 February 1944 

Fiscal Year 1945. 

Ref.: (a) Manual of the Medical Department, U. S. N. 

(b) Navy Department Bulletin of 31 December 1943, R-1747. 

1. Annual Medical Department allotment for the fiscal year 1945 is provided, 
for each vessel in commission, as at 1 July 1944, as follows: 

FY 1945 ALLOTMENTS 

Category Medical Dept. Allotment Category Medical Dept. Allotment 



AD 


$480.00 


ARG 


$240.00 


AE 


60.00 


ARH 


480.00 


AF 


60.00 


ARL 


240.00 


AG 


60.00 


ABSD, 


240.00 


AGC 


360.00 


AS 


480.00 


AGP 


240.00 


AV 


240.00 


AGS 


60.00 


AVP 


72.00 


AK 


60.00 


BE 


480.00 


AKA 


240.00 


OA 


240.00 


AKN 


72.00 


CB 


360.00 


AKS 


96.00 


CL 


240.00 


AKV 


72.00 


CM 


. 96.00 


AN 


60.00 


cv 


480.00 



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Burned News Letter, Vol. 3, No. 6 



FY 1945 ALLOTMENTS (cent.) 



Category Medical Dept. Allotment 



Category Medical Dept. Allotment 



AO $60.00 

AP 1,200.00 

APA 1,500.00 

APH 2,400.00 

AR 600.00 

ARB 240.00 



CVE $240.00 

CVL 360.00 

LSD 60.00 

PF 60.00 

PG 60.00 



2. The amounts indicated under Medical Department allotment in paragraph 1 
constitute allotments of the appropriation Medical Department, Navy, to each 
vessel in the respective classes. Each allotment is divisable into four equal 
quarterly apportionments, and availability for obligation is so limited. An 
allotment card will not be issued. Ships commissioned during the fiscal year 
will be granted automatically, without further reference to this Bureau, a pro 
rata share of the annual allotment. (E. g., a "CV" vessel commissioned during 
July would receive a full year's allotment. If commissioned during the month 

of August, the vessel would receive 11/12 of the annual allotment, etc.) Requests 
for allotment changes will be governed by paragraph 3022 (h) of reference (a). 
Allotment numbers will not be assigned to ships. In making requests for changes 
in allotment, the name of the appropriation (Medical Department, Navy) shall be 
stated, together with the fiscal year and the quarterly period in which change is 
desired. 

3. It will be noted, in paragraph 1, that there are -no medical supply depot credits 
established. Inasmuch as the Materiel Division, Bureau of Medicine and Surgery, 
has set up a system for recording- and reporting all issues of medical supplies 

by medical supply depots and storehouses to ships and shore stations, beginning 
with the fiscal year 1945, it will not be necessary to continue the granting of 
medical supply depot credits. Your attention is invited to the instructions in 
paragraph 3069 of reference (a). These instructions, as modified by current. - 
directives, govern the quantities of medical supplies to be carried in stock by 
ships and shore stations. No entry shall be made on NavMed Form "B" in 
column headed ''Supply Depot" of table 1. 

4. Hospital shipe, not included in the categorical list, will receive customary 
Medical Department allotment authorization, under estimate procedures as re- 
quired by paragraph 3012 of reference (a). 

5. Certain types of small vessels rarely require medical stores other than those 
listed in the supply catalog. It is intended that such vessels will be furnished 
necessary medical treatment and stores by the shore station, base, tender, or 
larger vessel to which regularly or temporarily assigned for operations or other 
purpose on a transfer basis. During periods in transit or on detached service, 



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Burned News Letter, Vol.- 3, No. 6 



RESTRICTED 



such vessels may obtain medical stores from any naval Medical Department 
activity, in the following order of preference: (1) Shore stations or base s regu- 
larly supplying similar vessels; (2) any shore station or base; (3) any NavMed- 
SupDep or storehouse; (4) other ships. Activities receiving such requests are 
directed to issue such essential medical stores as may be so requested. Shore 
activities located at ports where such vessels frequently call shall be prepared 
to render this service. Financial reports will not be submitted by vessel not 
having an allotment. 

6. Property accountability for vessels with or without allotment shall be main- 
tained on board in the usual manner and as prescribed in paragraph 3064 of 
reference (a). 

7. Medicines, and civilian medical, dental, nursing, and hospital services which 
may be required, in an emergency, for naval personnel attached to ships with- 
out allotments shall be obtained in the manner outlined in paragraph 3032 and 
3045, reference (a). The appropriation chargeable is "Medical Department, 
Navy." Further instructions on this matter are contained in reference (b). 

8. The cost of civilian medical, dental, and hospital services procured by ships 
having an allotment will be charged to a special Medical Department allotment 
maintained in this Bureau and should be reported on a separate NavMed Form ''B". 

9. Vessels listed in paragraph 1 shall prepare and submit an annual sundry- 
purchase requisition (NavS& A Form 76 and 76a) . Attention is invited to paragraph 

■ 3033 of reference (a) for instructions. — BuMed. L. Sheldon, Jr, 

To: All Ships and Stations. BUMED- Y-RBG 

P3-l/P3-2(064-42) 

Subj:' Venereal-Disease Educational 

Leaflets, Distribution of. 15 February 1944 

Ref.: (a) General Order 14, 13 May 1935. 

(b) General Order 156, 13 Oct. 1941. 

(c) Joint Itr. NAV-147-RNC-P3-1(85) , BuMed P3-2/AT1 3(021-40) , 
25 Mar 1942. 

1. Reports to BuMed indicate that the venereal diseases continue to constitute 
a major problem in preventive medicine. Statistical data for the calendar year 
1943 indicate that an upward trend in the incidence rate may be anticipated. It 
is essential, therefore, that all methods of venereal-disease control, as outlined 
in references (a) , (b) , and (c) , be intensified, especially with respect to educa- 
tional activities. 



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Burned News Letter, Vol. 3, Ko. 6 RESTRICTED 



2. To aid in the indoctrmation of, all personnel in the basic facts of venereal 
disease, with special emphasis on prevention, BuMed has prepared a group of 
six educational leaflets which supersede the pamphlet "Sex Hygiene and Vene- 
real Disease." These leaflets will be distributedr at approximately monthly 
intervals over the next 6 months. Ships and advanced bases will be furnished 
leaflets to the extent of 30 per cent of complement. All naval districts and 
river commands, and air and amphibious training commands (continental), will 
be furnished leaflets to the extent of 50 per cent of complement. Bulk supplies 
will be delivered to district and command headquarters for redistribution to 
stations under their jurisdiction. Navy, Marine Corps, and construction recruit 
training centers will be furnished leaflets sufficient for 100 per cent of present 
and future complements. 

3. The senior representative of the medical department of each ship and station 
is responsible, with the approval of the commanding officer, for ultimate distri- 
bution of leaflets. All personnel are to be given an opportunity to read each 
leaflet. 

4. During 1943 more than one-third of a million sick days were recorded for 
new admissions of venereal disease, not including sick days of cases developing 
complieations. It has. been demonstrated that a -Significant proportion of -all 
venereal^disease infections cah be prevented by aggressive application of edu- 
cational and prophylactic measures . Thus every patient admitted for venereal 
disease must be considered a failure of educational discipline. The tactical 
implications of venereal-disease casualties should not be underestimated. There- 
fore, as' emphasized in paragraph 6 of reference (b) , the application of an effective 
educational prophylaxis must be considered a continuing responsibility of the 
medical department and commanding officers. --BuMed. L. Sheldon, Jr. 



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